Joseph H. Stephens

Suicide in patients hospitalized for schizophrenia: 1913–1940.

From a sample of 1357 schizophrenic patients hospitalized between 1913 and 1940 at the Phipps Clinic, we have follow-up data on 1212 (89%) cases, with a mean length of follow-up of 11 years. Of these 1212 patients, 28 (2%) are known to have committed suicide. Suicide was significantly correlated with 1) previous suicide attempts, 2) depressive symptoms, 3) preoccupation with suicide, 4) affective illness in close relatives, 5) poor premorbid social and work history, 6) sexual worries, and 7) psychomotor agitation. Marital status, gender, age at onset, age at admission, number of previous admissions, condition at discharge from Phipps, length of hospitalization, the presence of any type of delusions or hallucinations, alcohol problems, paranoid or catatonic features, and utilization of shock therapies were not significantly correlated with subsequent suicide. The seven variables significantly correlated with suicide enumerated above were chosen to construct a scale suggesting which patients were at high risk for suicide.

Perceptual span in schizophrenia and affective disorders.

Perceptual span was assessed in schizophrenic, bipolar affective disorder-manic, bipolar affective disorder-depressed, and nonpsychotic inpatients. Both schizophrenics and manics processed less information than depressives, and did not differ from each other. This suggests that reduced span may be a concomitant of psychoses characterized by distractibility and thought disorder, rather than a trait specific to schizophrenia.

Long-term follow-up of patients hospitalized for schizophrenia, 1913 to 1940

From a sample of 1357 schizophrenic patients hospitalized between 1913 and 1940 at the Phipps Clinic, we particularly studied 484 patients with follow-ups of 5 or more years. Of the sample of 1357 patients, 28 (10%) committed suicide. None of the suicides were included in the sample of 484, which also eliminated all patients with any previous psychiatric admissions or episodes of mental illness, even without hospitalization. On follow-up, only 13% of the 484 were rated recovered, whereas 58% were rated unimproved. Long-term global follow-up was highly correlated with discharge status. Subgroups retrospectively diagnosed by DSM-IV criteria were significantly related to long-term follow-up in the sample of 484 patients, there being a continuum of poor outcome ranging from the diagnoses schizophrenia through schizophreniform to schizoaffective. Poor follow-up was significantly correlated with poor premorbid history, gradual onset, lack of depressive symptoms and heredity, seclusive personality, lack of precipitating events, lack of confusion, single status, onset before age 21, delusions of control, onset 6 months or more before admission, and emotional blunting. These variables were used to construct a validated prognostic scale. More recent treatment results have been contrasted with these findings from an earlier non-drug treatment era.

Characteristics and long-term follow-up of patients hospitalized for mood disorders in the Phipps clinic, 1913-1940

From a sample of 2809 mood disorder patients hospitalized between 1913 and 1940, we selected for detailed study 914 patients with at least a 5 year follow-up and 103 patients who committed suicide within 5 years of discharge. Patients with clearly mood incongruent delusions or an onset associated with a physical illness were excluded. Based on the presence or absence of manic symptoms, this cohort of 1017 cases was divided into 297 bipolar and 945 unipolar patients. Bipolar patients had an earlier age of onset and admission and were more likely to be delusional and hallucinated. They also had more sudden onsets, more previous admissions, worse premorbid characteristics, and more problems with alcohol, but more patients were discharged as recovered. Unipolar patients were more often female and married, more likely to have made previous suicidal attempts, and more likely to have experienced a precipitating event. On a mean follow-up of 13.5 years, only 11% of the bipolar and 22% of the unipolar patients experienced no futher episodes of mania or depression. Of the bipolar group, 77% had to be rehospitalized, as did 56% of the unipolars. Only 2% of the sample had manic episodes with no lifetime depressions; this small group had the best outcome. One third of all the patients were rated unimproved on follow-up. Thirteen percent committed suicide, usually within 1 year of discharge. Bipolar patients had the worst outcome, with 43% rated unimproved. The sample was split by odd or even case number and one half was used to construct a prognostic scale significantly correlated with long-term outcome. It was cross-validated on the other half of the sample with little shrinkage. Patients with non-drug-treated affective disorders hospitalized half a century ago were found to have polyepisodic illnesses with a frequently chronic course.

Prognosis as the critical variable in classification of the functional psychoses.

Kraepelin used a disease entity concept to define the two major functional psychoses (i.e., distinctive patterns of onset, symptoms, and course of illness). There have been many subsequent studies using patient outcome or distribution of illness among relatives to test the validity of these nosological classes. Differences between chronic schizophrenia and (predominantly nonchronic) affective disorders are often reported, but it is difficult to discern whether these differences are associated with diagnostic symptomatology rather than premorbid prognostic status. The evidence suggesting a genetic link between good prognosis schizophrenia and affective disorders may be misinterpreted if premorbid prognostic processes are the distinguishing heritable components between chronic schizophrenia and nonchronic illnesses. Which components of severe psychiatric disorders are heritable is not yet clear. The developmental, psychological and neurological processes associated with premorbid and early morbid characteristics of illness appear good candidates. Considering such variables as prognostic (early morbid or premorbid) rather than diagnostic would permit examination of class assignment (e.g., schizophrenia, bipolar affective disorder) and premorbid development. The literature now suggests that chronicity in psychiatric illness breeds true and that symptom constellations breed true. Both of these views may be correct, and the taxing study design required to simultaneously study these two attributes of disease entities is warranted. This may establish good prognosis schizophrenia as a “third psychosis,” or may affirm its standing within traditional nosology.

Long-term follow-up of patients with a diagnosis of paranoid state and hospitalized, 1913 to 1940.

From a sample of 239 patients diagnosed paranoid state and hospitalized between 1913 and 1940 at the Phipps Clinic, we particularly studied a group of 60 patients without previous hospitalizations, consisting of 57 patients with follow-ups of 5 or more years, and 3 patients who killed themselves (the ultimate follow-up) less than 1 year after discharge. These 60 patients had been retrospectively diagnosed with delusional disorders by DSM-IV criteria. On follow-up, 27% were rated recovered, whereas 52% were rated unimproved. Long-term follow-up was correlated with discharge status. Poor follow-up was significantly correlated with seclusive personality, poor premorbid history, onset 6 months or more before admission, gradual onset, lack of insight, single marital status, and lack of precipitating events. A prognostic scale constructed from the first four of these variables was predictive of long-term outcome. More recent, better treatment results have been contrasted with these findings from an earlier non-drug-treatment era.

Which AB scale? A comparative analysis of several versions.

The AB scale has proven to be a very useful tool in psychotherapy research for a simple and compelling reason: it predicts a psychotherapists potential effectiveness. However, research with the scale is complicated by the current existence of nine different versions. The purpose of this paper was to clarify this situation by means of a comparative analysis of several of these versions. This comparative analysis was conducted by two methods: 1) a review of the “developmental history” of these nine versions, and 2) an empirical study of the accuracy of several versions of the scale in identifying successful therapists. The historical review of the development of the scales revealed that two of the versions and one of the scoring methods had psychometric shortcomings, leading to the suggestion that they probably should not be utilized in research. The empirical portion of the comparative analysis suggested that, of the remaining seven versions of the test, three were the strongest, in the sense of being most reliable and valid. Since at the present time there are no data permitting any distinctions among these three versions, the best strategy for current research is to use all three and to compare their relative effectiveness. Such a strategy still leaves researchers with a choice of three versions, but this represents considerable gain over the nine possibilities which existed prior to this analysis.

Inpatient diagnoses during Adolf Meyer's tenure as director of the Henry Phipps Psychiatric Clinic, 1913-1940.

Between 1936 and 1950, detailed abstracts were prepared on all patients admitted to The Phipps Psychiatric Clinic from its opening in 1913 through 1950. Of these abstracts, 74% contained follow-up reports. Except for four papers on schizophrenia and affective disorders published between 1939 and 1943, none of this material has ever been analyzed. The present paper, the first of a series, examines the 8172 first admissions from 1913 through 1940, the period of Adolf Meyers tenure as Clinic Director. Based on discharge diagnoses, we have sorted the patients into eight diagnostic groups with the following frequencies; schizophrenia, 17%; paranoid state, 3%; manic-depressive, 7%; depression, 27%; organic, 20%; neuroses, 15%; substance abuse, 6%; psychopath, 5%. Our manic-depressive group contains cases discharged primarily as hyperthymergasia, mania, or manic depressive insanity (MDI). Of the 349 cases diagnosed MDI at discharge, 10 had neither a history of nor present symptoms of mania, and these were put in the depression group. Frequencies for most of the diagnoses remained remarkably stable over the 28-year period. Only 9% were discharged recovered, whereas 43% were rated unimproved. Mean length of hospitalization was 76 days, with 10% of the patients readmitted. The mean length of follow-up was 9 years. Correlations of diagnoses, year of admission, length of stay, condition at discharge, age, sex, readmissions, change of diagnoses, somatic treatment, length of follow-up, and deaths in the clinic are presented. Meyers influence on diagnostic practice is discussed.

Effect of person

The role of the experimenter in the behavioral study, although recognized by Darwin, Pavlov, psychiatrists and others, has not been adequately evaluated in terms of the quantitative measures of the CR. Our study in this paper concerns especially the cardiac changes induced by “Person” in normal and pathological animals—monkey, dog, cat, opossum, guinea pig and rabbit. Owing to the greater sensitivity of the cardiovascular and respiratory systems, these are more reliable and delicate measures than the usual somatic muscular ones. The Person can be used as an unconditional stimulus on the basis of which conditional reflexes are formed. Person has an especially pronounced effect on neurotic animals—shown often in a more pronounced way in the cardio-respiratory responses than in the more superficial behavioral ones. This Effect of Person may provide insights into the production of neurosis as well as some of the beneficial effects of therapy, e.g., the personal factor of the therapist.